The ethical position of the American Psychiatric ( APA) Association and the code of ethics for psychiatrists about torture came to prominence about 10 years ago when I was Speaker of the Assembly of the American Psychiatric Association. At this time the Assembly endorsed the position of the Board of Trustees of the APA about this issue. Recently this topic has surfaced again as described in the article below in the the APA News . I would suggest that this article should be read and then for further clarification I would like to present a video interview that I had in 2009 with the late Dr. Abraham Halpern. Dr. Halpern was a prominent American psychiatrist who was leading spokesperson on number of ethical issues.
And now please view the interview that I did with Dr. Halpern on this subject in October 2009. https://www.youtube.com/watch?v=oULhHzC8E_8
Please feel free to add any comments that you have about this subject in the comment section below and they will be published shortly.
As details emerge from the suicide/murder that was Germanwings plane disaster, there are important questions being raised about how should a mental health therapist approach patients who may have the potential for violence towards themselves or others.
I would suggest that the following questions should be considered.
Just having fleeting suicidal thoughts does not make someone a risk for hurting themselves. Similarly, having an angry murderous thought toward someone who you might resent does not make you a potential killer. There are many factors which a clinician must consider in evaluating the suicidal and danger potential of a patient. Is the patient psychotic? Is the patient having a severe depression which might include not sleeping or eating, crying, losing weight, etc ? Has the person acted on impulses in the past? Is there a history of violence towards self or others? Does the therapist and the patient feel comfortable that the patient would talk to the therapist if he or she felt that the feelings were intensifying? Does the patient have an immediate means to violence, such as access to a gun? Are there family members who can help monitor the patient in between sessions? These and many other factors enter into the evaluation of the seriousness of the threat that the patient may have to themselves or others. This is tricky business, but mental health professionals do it all the time.
The overwhelming majority of people with mental illness are not dangerous to themselves or other people. It should also be noted that mental health therapists do not have a sure method of predicting dangerous behavior in the future. We may be good in retrospect at explaining behavior and actions as the result of psychological factors (called psychic determinism), but we cannot claim the ability to predict behavior with great accuracy. We know a great deal about various forms of mental illness such as schizophrenia where there is a break with reality. In most of these situations, the diagnosis is quite clear. Depression affects a very large number of people. There is a wide range of etiological factors of depression from grieving and situations involving loss and disappointment to biological types of major depression which can come on without any particular relationship to a loss or disappointment. There are also can be variations of mood such as bipolar or major depression which can even be at a psychotic level.
Suicidal thoughts often accompany various forms of depression. There can be passive thoughts such as a person who does not care about anything and might not want to eat or drink or take care of themselves. In such situations, a person frequently expresses the idea that they do not care if they wake up or not. Sometimes, persons may act suicidal or make suicidal threats or even try to hurt themselves as part of “cry for help.” In other words, the main thought of such person would be a desire to be stopped and given help. This doesn’t mean that they might not actually seriously hurt themselves.
People can become depressed to the point where they feel they cannot tolerate life or may feel worthless and that they do not deserve to live. Such a person might choose a suicidal method that would be more likely to be fatal. In some situations, this person, is intent on making a statement to someone else in their life, and they would want their suicide to have an impact on a family member or someone close to them. Sometimes, tremendous anger at themselves or others is part of the motivation for suicidal thinking.
As it is well-known by police, some suicides are connected with a murder of someone else, usually a person well-known to the perpetrator. This may frequently be a family member or someone where there is an intense conflictual relationship. Sometimes, the suicide and the murder of the other person may involve a work situation such as a boss or a co-worker. The circumstances of someone being fired or humiliated at work or school might fit in to this category. These are not common, but they do happen.
This brings us to the situation of a suicide and multiple or mass murders. While such situations are extremely rare, they become very well publicized and well remembered. Sometimes they become examples for copycat acts by someone else. Limited research upon this group suggests that major depression is frequently present in the person who carries out this act. Also anger and rage and the feeling of being wronged may be present. There also may be some grandiose or narcissistic feelings where the perpetrator wants to become famous or remembered. While alcohol and drugs can always be a factor as it can loosen up one’s conscience and any inhibitions, it is not always present in this particular type of suicide connected with mass murder, since it often takes careful planning and requires a clear mind to carry them out. In retrospect, a study of each of these cases usually reveals particular stresses, rejection, and usually tremendous anger.
Can a therapist see the makings of a potential catastrophe and do something to prevent it? The answer is yes, we do that all the time when we work with people who have suicidal thoughts, but we can’t do it every time. Treatment works! But not all the time. There are many people who have experienced severe depression even with suicidal thoughts and even may have made a suicidal attempt and then recovered with treatment. Treatment can be psychotherapy, medication, or both. This is the reason that therapy has to be available, and a person should be able to enter the therapy and feel secure that they can express all their thoughts in a safe environment
But what if the therapist concludes at some point in the treatment that the patient is an immediate serious threat to themselves or someone else? At that point, there is an obligation for the therapist to hospitalize the patient. Hopefully, the patient would agree to such hospitalization. But even if the patient does not agree, there is a procedure (that varies from state to state) in which patients can be hospitalized against their will. In the State of California, it is called a “5150”, and if necessary, the police will assist a therapist based on the information provided from the mental health professional to take the patient to the hospital. Then at the hospital, based on the information provided by the therapist and any family or friends available plus another evaluation by a mental health professional at the hospital, a patient can be legally hospitalized against his or her will. Then there can be subsequent legal proceedings to extend this hospitalization.Now, you may ask isn’t this breaking the confidentiality of the doctor-patient relationship? Yes of course it is, but this is obviously in the patient’s best interest. On occasion, during the course of therapy, the patient will ask me, “Is everything we say in therapy confidential?” I would reply, “Yes, unless I feel you were a true danger to yourself or someone else, and then I would act accordingly.”
There is another situation to consider. What if the therapist becomes aware that the patient is seriously suicidal and/or a danger to someone else but they are not in present in the therapist’s office? Perhaps, they have left a message for the therapist or they do not show up for an appointment and the family described some behavior that the therapist understands means a danger situation to the patient or someone else. In such a case, the therapist is obligated to notify the police and have them attempt to find the patient and institute a “5150” based on the information that the therapist has provided. In California, the law further mandates that if the therapist feels that there is a clear danger to someone else , and the therapist knows who that person is, the therapist has to act according to the Tarasoff case. The Tarasoff case involved a situation at the University of California where a therapist knew that the patient would attempt to hurt another person. As a result of this case, in California, if a therapist believes that another person is in danger, the therapist must notify that person or be sure that that person has been informed by the police. Every effort must be made to contact the person who is believed to be in danger. So therefore, reflect on the thought, what if the therapist is treating an airline pilot and the therapist came to believe that the pilot who was not available to be brought to the hospital but might be flying a plane which he could be planning to crash as part of a suicide murder. According to the Tarasoff precedent, the therapist would be obligated not only to notify the police and try to hospitalize the patient, but would also be obligated to be sure the airline was notified of the potential danger.
So now let’s return to the three questions which I raised at the beginning of this article.
My answers would be as follows:
I am not an attorney nor do I claim expertise in legal issues which often differ from state to state. I also am not necessarily reflecting the ethical position of the American Psychiatric Association or other professional organizations. I am writing as one experienced psychiatrist who has confronted variations of these questions in clinical practice and has discussed such issues with my colleagues, mentors and students over the years.
I would also recommend a recent article in the New York Times by Erica Goode dated April 9, 2015 titled, “The Mind of Those Who Kill, and Kill Themselves.”
Dr. Blumenfield is the Sidney Frank Distinguished Professor Emeritus at New York Medical College. He currently is in private practice in Woodland Hills, California. For more information about Dr. Blumenfield go to http://mblumenfieldmd.com/
How We heal and Grow : The Power of Facing Your Feelings by Jeffery Smith, M.D.
How We Heal and Grow: The Power of Facing Your Feelings by Jeffery Smith, M.D.
I was recently asked by my colleague and friend Dr. Jeffrey Smith, to write the Foreword for this new book that he has written. I was pleased to find it an excellent book. He offers a fresh and sensible way to look at how people develop dysfunctional patterns and facing feelings that have been avoided is the pathway to healing growth. He covers the full range of human problems from quirks to serous personality issues. He discussed the work of Freud, Mahler, Kernberg and many others including his own work. Interestingly the book is directed towards the lay public and I am sure will be received. However it really also belongs in the hands of therapists and any mental health professional who is involved with therapy. Dr. Smith has been teaching this subject to psychiatry residents and other psychotherapists for many years and is always very well received. He approaches the subject from a developmental point of view. He points out how most of us have pockets of immaturity and how to outgrow them. Dr. Smith discusses how and why the minds resist change. One of the central themes of Dr. Smith’s explanations is the phenomenon of catharsis where our underlying raw unprocessed feelings emerge and lose their power over us and are transformed when we share them with a therapist in the context of connection and safety. He describes this process and how it brings about an almost immediate change to the pathological emotions. I tend to look at the need for catharsis as something that has to occur over and over again which we often refer to as working through process. We do both agree that catharsis is an ongoing part of therapy. While this therapeutic work does require the empathic presence of the therapist. Dr. Smith also examines how some of this work may be able to done singularly when the person is trained in mindfulness in the Yoga and Buddhist tradition. The range and scope of the book is quite wide. He includes discussion of anxiety symptoms, trauma and depression although I felt he was little light on this latter subject particularly in regard to the role of loss. There is fascinating discussion on the dynamics of Multiple Personality Disorder in which he is a one of the few therapists with significant experience treating patients with this condition. Dr. Smith also brings his rich experience in treating addiction into the book. He shares where dynamics and developmental experience is important and where the here and now social interaction is crucial. Included in the book is one of the best discussions of conscience and superego that I have ever come across. There is also and excellent section on the narcissistic personality and a description of how to understand a parent who had this condition and how to deal with important people in your life who have it. This is really a unique book that should have great appeal to therapists, students learning therapy and people interested in understanding their own emotional issues as well as those around them. I can also picture how this book may be very useful for people entering therapy, It will alert them to what to look for in themselves. It may very well facilitate the therapeutic process. In fact, I plan to give a copy of it to some patients who enter therapy with me. I am very pleased to conclude that Dr. Smith has made an outstanding contribution to our profession as well as to the education of the public about mental health and the therapeutic process.
The following is a shortened edited version of the Presidential Address which I gave at the 2014 Annual Meeting of the American Academy of Psychoanalysis and Dynamic Psychiatry held in New York May 2014. This article in edited form will also appear in the next issue of the The Forum, a magazine published by the American Academy of Psychoanalysis and Dynamic Psychiatry , Any comments are welcome at the end of this article
The American Academy of Psychoanalysis and Dynamic Psychiatry 75 Years From Today
Michae Blumenfield, M.D.
The theme of this meeting has been 75 Years After Freud and my talk in closing this meeting is the Academy 75 Years from today
Now let us look 75 years into the future – The year is 2089. I have a fantasy that the President of our organization will be my grandson Obi, who recently turned 5 years old now but at that time he will be 80 years old….. in the PRIME OF HIS LIFE. Obi’s life expectancy is to be 79-86 by projections today but many believe with scientific advances that we will have, it will be much longer. In fact, in an article in the Journal of Anti Aging Medicine a few years ago, 60 gerontologists from leading universities all over the world were asked for estimates regarding the development of future life expectancy for a person born in the year 2100 – 86 years from now. The median prediction was 100 years whereas the mean was 292- since 3 people predicted over 1000 years. – showing that there were some Death deniers.
I am doing a project where I am recording an audio interview with the past Presidents of the Academy and I had the pleasure of doing interviews with Milt Zaproloupus and Mary Ann Eckhardt both over 100 year old and going strong
So perhaps 80 year old Obi in his prime will be President of the Academy and he will be standing here or perhaps he will be speaking to us via Hologram .
One of my son’s is a TV producer and he said to me why don’t you do a live demonstration and project yourself into the lecture hall. I looked into this technology which is definitely available but now costs $100,000 so I thought I would save the Academy some money and let’s wait until the cost comes down. Holographs or not – In 75 years from now our President will be here surrounded by large screens where perhaps simultaneous gatherings will be taking place all over the world in lecture halls or in their offices watching and participating in this meeting
I believe it is fair to say that we will be an international organization. This year during my presidency we changed the international dues schedule based on World Bank calculations so our international colleagues can afford to join. Those of you teaching in the CAPA (Chinese American Psychoanalytic Alliance) know about the nascent but growing interest in psychodynamics in China which will be full grown in 75 years. In fact I predict before 75 years we will change our name from the American Academy of Psychoanalysis and Dynamic psychiatric to just the Academy of Psychoanalysis & Dynamic Psychiatry. I believe we will still be aligned with the APA and American Psychiatry …but if we follow the trends of international psychiatry so we can also be aligned with international psychiatrists who value psychodynamic psychiatry.
We are in the midst of a technology revolution that clearly affects the way we communicate with each other. Many of us are doing therapy using Skype or newer technology. I am treating a Chinese psychiatrist in China via this video technology 2x/week as part of the CAPA program Chinese American Psychoanalytic Alliance. I have treated college students who when they left to go to out of town college continued seeing me via Skype . Many of you are doing similar things
In 75 years from now we will also be teaching psychodynamic psychiatry via the latest technology. Many of you are already teaching and supervising via Skype or similar technology. I have had the exciting experience of teaching a class by SKYPE in psychoanalytic technique to Chinese students simultaneously in three different cities in China for CAPA
My colleague Jim Strain and I have set up a program where we have offered long distance courses to 3rd world countries and have taught psychosomatic medicine via Skype or similar technology in Colombia South American and Rwanda.
It is also interesting to consider what role will the Academy play in providing teaching courses in psychoanalytic and psychodynamic theory and treatment in the United States. While at present this is being provided by the residency programs and psychoanalytic Institutes, there are many changes going on now in the systems of post graduate education. It may very well be that in future years the Academy will take a very important role in providing the latest teaching of psychodynamic psychiatry and will do much of it using the latest techniques delivering classes and perhaps supervision directly.
After I prepared this talk, I opened the NY Times and I learned that 3D Virtual Reality will be here very shortly. Facebook has paid 2 Billion dollars for a Virtual Reality Company that will give people the illusion that they are physically present in a digital world. The translation to Long Distance Learning and Therapy sessions won’t be far behind
But the BIG question is what will our theory and therapy look like in the distant future????
In order to anticipate the role of psychodynamic and psychoanalytic therapy in 75 years from now we have to try to anticipate what will the state of the art of science, medicine and general psychiatry?? Let’s remember how far psychiatry, medicine and modern technology has come in the past 75 years
Although the effects of penicillin was discovered a few years earlier it wasn’t until 1939- 75 years ago that a usable product was developed which we would say was the first antibiotic
In 1938 76 years ago Cerletti and Bini introduced ECT therapy
75 years ago – it would be another 10 years until Lithium therapy for bipolar was discovered by John Cade
75 years ago it would be another 12 years before chlorpromazine the first antipsychotic medication would be introduced.
Forget about computers 75 years ago regular TV was just started in the US Bill Gates father was 14 years old and his mother was 10 years old
We know scientific advances occur exponentially – meaning that they will occur much faster in the next 75 years then they did the previous 75 years ago.
So what clues do we have what psychiatry will be like in 75 years from now? And what predictions can we make?
We will have a much more complete understanding of the genetic and biological nature of Major Depression, Schizophrenia, Bipolar Disorders, PTSD and Dementia as well as entire new sophisticated methods of treating them and preventing much of the symptoms manifestations. Just looking at the journals which come across my desk in one recent month I noted:
The role Apolipoprotein e-4 allele gene and depressive symptoms as well as the relationship to cognitive disorders
Psychosocial risk factors associated with elevated plasma peptide endothelium
Genetics predicators of lithium response
Relationship between heart disease and depression
Relationship between depression and diabetes
Role of inflammation and psychiatric symptoms
The Role of Transcranial Stimulation on Depressive Disorders
Neuroimaging differences in patients with Borderline Personality Disorder
You also may have seen a recent article the Academy Journal by Michael Stone which discussed Borderline personality related to hyper-reactivity of the Limbic System
I believe that it is fair to say that in 75 years from today, modern medicine will have extremely effective medications, injections of genetic material, brain stimulation , possibly even some type of surgery as well as techniques we have never heard of that will be effective in eliminating, controlling and preventing so much the psychiatric manifestations that we see today in our psychiatric practice. Treatment will be complicated and will require not only a understanding of the state of the art science and medicine but an understanding of human behavior and interactions. Therefore they will still be best treated by physicians who are especially trained in medicine as well as in human behavior and interaction by which I mean psychiatric specialists. Of course it is possible that some of these treatments will be relative simple and will not require specialists and many conditions may be treated by general medical physicians as they often are today.
However- No matter how effective these treatments are, they won’t be able to eliminate the effect of human interaction especially during child development on personality development, conflictual feelings such as love, hate, guilt, empathy, object choice, positive and negative identifications, competitiveness, passiveness, creativity adaptation, maladaptation, happiness and sadness, fulfillment and lack of fulfillment.
I believe that EVIDENCE BASED Research will continue to accumulate which will show that the state of the art intensive psychodynamic psychotherapy undertaken in adulthood will be the most effective therapeutic method to bring about an emotionally full filling life. It will become known and accepted that the previously mentioned biological based treatments although immensely successful in treating major depression, OCD, bipolar, PTSD, panic disorder, perhaps social phobia, hopefully Schizophrenia , hopefully various forms of autism WILL NOT be able to address the effects of human interaction, thoughts and fantasies on the developing personality nor on the ultimate satisfaction with self and relationships and with one’s place in the world BUT a meaningful modern psychodynamic therapy will do so.
I believe evidence based research will show that biological based treatments mentioned previously will be extremely effective in eliminating biological and genetic psychiatric conditions and may very well be able to mitigate the emotional response to relationship issues, the emotional response to loss self esteem, PTSD etc. but certainly will not prevent these situations, external and internal which cause anxiety and depression, from reoccurring. But I also believe that evidence based research will build on the existing body of knowledge that strongly suggests that meaningful intensive psychodynamic therapy – let us say for sake of discussion – about two years of psychodynamic treatment- will be the most effective for doing such and produce the best results for having the least debilitating symptoms and the opportunity for a more full filling life. In the past 10 years there has been an increasing amount of Evidence Based Research and discussion about the efficacy of Psychodynamic Therapy.
If science research shows this form of treatment is effective – People will want it and expect it! The questions remaining are who will do it, who will pay for it and how will it be different than the treatment we do today ??
WHO WILL DO IT?
Most likely the newer form of psychiatric treatment dealing with newer medications, genetic treatment, brain stimulation, other biological interventions yet to be conceived will be handled by physicians with special interest and training in human behavior – in other words, psychiatrists. As is often the case today- when psychotherapy is indicated the same doctor who is handling the biological forms of treatment if trained in psychotherapy is in the best position to do psychotherapy also . And that would be psychiatrists.
Recently I have been interviewing past presidents of the Academy and asking them about the pathway of their career. Many of them as have I, were drawn into this field by first being fascinated with the working of the brain and then ultimately finding that, as challenging as the interventions we could do as physicians- it was even more interesting and rewarding to interact with patients and help them make meaningful changes through psychodynamic therapy. I can see his happening in the future, as generations of medical students will gravitate towards psychiatry as tremendous advances are made in treating mental conditions BUT ultimately they will realize that in addition to these interventions, the ultimate intervention for many people will be a period of intensive psychodynamic therapy.
OF course as is the case now- the amount of people of wanting and needing psychodynamic psychotherapy will well exceed the number of psychiatrists available to perform this therapy. So there is every reason to believe that our colleagues in other mental health professions will continue to develop their skills in psychodynamic psychotherapy and will be performing this service as many of them are now.
But let us imagine for a moment that time and research has determined that even after all the latest bio-genetic, brain stimulating, psychopharm forms of treatment, it has been clearly shown that an intensive psychodynamic therapy makes a big difference in people’s lives…… WHO WILL PAY FOR IT?
In 75 years from now it seems clear that we will have some form universal health care program – maybe single payer or maybe more like the current health care that is being rolled out. IT most certainly will cover the biological, genetic, new medical brain stimulating, modern psychopharm treatment etc and if the scientific evidence is clear the people will demand and our universal health care could very well cover the 2 years of psychodynamic treatment I envision will be needed and wanted by so many people. BUT what if evidence is there to prove that it is worth the time and money but the future political climate won’t allow it……?
Are there any other possibilities other than the rich shell it out and it becomes a treatment for the elite? Remember we anticipate that median life span may very well be 100. People are going to living longer and be healthier longer. People will be working and living much longer than today.
Today, if we get a mortgage on our home it is for 20 or 30 years because people are expected to have that long of a productive working life. That also was the basis for college and post graduate loans. It is worth it, if people correctly believe that psychodynamic therapy in their 20s 30s or 40s will make a difference in the next 60 to 80 years of their lives, but intensive psychodynamic therapy is going to cost them over a two year period maybe 5-10 % what their mortgage might be worth, why not take a mortgage on their psychological well being? It could be attached to their mortgage which will will be 30 \or 40 year loans or have such loans institutionalized as education loans are these days especially since people may be living and working 10 or 15 years longer then anyway.
How will Psychodynamic therapy be different than it is today?
In order to anticipate this question , we would have to know how our lives will be different. How will childhood experiences be different? How will families be different ? How will technology impact our lives? What degree of poverty will IMPACT child development or lack of it . We are pretty sure that people are going to live longer and therefore people’s psychodynamics are going to be influenced by growing up in multigenerational families. There will be more great grandparents as well as grandparents interacting with the developing child . Perhaps more complicated patterns of competition and identification.
What will we learn about children being raised by LGBT parents ?
How will some of the assumptions and psychodynamic theory be changed and modified as we understand the kids developing in same sex families? Similarly, new understandings will emerge as in the future as we have large numbers of people who are test tube babies perhaps genetically altered.
I have observed and have written elsewhere on this blog about the tremendous drive of adopted, children or children raised by one biological parent to connect in some way with their both biological parents and their families whenever possible –even if adopted at birth or raised by one biological parent.
We just now beginning to see the emergence of children who are digital natives. – meaning they have been using digital devices since they their earliest memory – often starting at age 2 and 3 . How will this play out in 75 years after 3 or 4 generations of this child raising component with even newer technology? How will their object relations, socializing patterns etc be impacted by this this technology in their lives?
The latest statistics show that today 1/3 of people getting married have met online. So it is probably safe to assume in 2089 most serious relationships will be started online. Those of you who saw the movie HER realize that people are considering that it may be possible to establish a meaningful relationship with a so called person who is only a computerized program. Consider the psychodynamic implications of that!
As therapists we are always interested in the patients emotional reactions to their thoughts and fantasies, especially when they occur during a therapy session. This is also an important aspect of transference and countertransference. We also use our own emotional reactions to what is being discussed in therapy. We know also that emotional reactions are accompanied by physiological changes throughout the body including changes in activities in various parts of the brain. All of these emotional responses can occur before there is conscious awareness of the emotional reactions. I usually wear a fit bit on my wrist. This is wrist band which measures my heart rate and number of steps I take – it also recognizes when I am sleeping. This is a first generation device. Similar devices are being developed that measure BP, pulse respiration rate and future devices are expected to have the capacity to measure cortisol levels and even other hormones including sexual arousal etc. Perhaps a little band around the head would measure electrical activity of the brain. The capacity to wirelessly project any measurements to a computer screen or projection screen already exist. So I can imagine that if the patient and the therapist each wore these devices we would have the ability to measure all these internal manifestations– ALL which could be observed by the therapist or the patient or possibly both during the therapy session.
Obviously I really don’t know what is in store for our organization or the future of psychodynamic psychiatry and our profession. I do know that there is going to be lots of change. The tradition of our Academy has been one that respects the work done in the past but always has a willingness to consider new ideas. I hope we will continue to do this and that we will take steps to continually change our organization to meet the needs of our profession and embrace what is to come 75 years from now or 150 years after Freud AND BEYOND
Any comments are welcome below